industry & reform
measure to determine the merit of the
reforms in home care is the extent to
which it achieves its main objective of
supporting older people’s independence,
health and wellbeing, and their ability to
remain at home. The evidence shows that,
for some people, personalised budgets
have improved their ability to make
choices regarding their provider, and they
are more likely to report feeling in control
of their daily lives.
This is a key attraction of the rhetoric
of personalisation – its claim to offer both
choice and control via the mechanism
of a direct payment or individual budget.
However, as pointed to above, the
bulk of evidence, including research
and evaluations commissioned by the
Department of Health, indicate an overall
reluctance to change providers.
On the other hand, this benefit is not
equally available to all. Those on waiting
lists are missing out, as well as older
people receiving services that partially
meet their needs.
Older people from disadvantaged
groups – including Aboriginal and Torres
Strait Islander people, those from culturally
and linguistically diverse backgrounds,
the poor, and those living in remote
communities – are missing out.
And it’s not because of language barriers
or cultural preferences, but because they
are ineffective consumers when it comes
to purchasing social care.
A report to the United Nations Economic
and Social Council defines ‘disadvantaged’
as those groups that encounter structural
obstacles (that is, obstacles created by
society) when trying to access resources,
benefits and opportunities.
These obstacles derive from the
relationships of power that exists in all
societies and the relative value that society
gives to each group. The structural causes
that underlie disadvantage include race,
ethnicity, gender, religion, indigenous or
national origin, and socioeconomic status.
As pointed out in a Consumer
Affairs Victoria report on consumer
disadvantage, the two major dimensions
of consumption are the market dimension
and the personal dimension. When
it comes to aged care, the market
dimension includes complex products
and transactions, control of information
by suppliers, marketing strategies and
so on. The personal domains include
literacy levels, level of trust, negotiation
skills, impairment, levels of education
and resources.
Calls to better support older people
who are disadvantaged through better
information and better resources fail to
recognise the pervasive and enduring
impact of poverty, limited education,
limited literacy, remoteness, disability,
trauma and neglect on the ability of older
people to seek information, compare
products, negotiate services, reassert their
individual rights and make complaints.
Older consumers with normal capacities
and in ordinary personal circumstances
may still be vulnerable to market-driven
care, due mainly to the complexity of
the products being sold and the risks
associated with making choices with such
profound implications for their health,
wellbeing and quality of life under stressful
and time-pressured circumstances.
Older people from disadvantaged
groups face the above plus the
compounding impact of constrained
capabilities and adverse circumstances.
The government’s response to
consumer vulnerability has been to
recognise the importance of strengthening
consumer protections rather than to
reconsider the merit of a market-driven
care model.
This is evidenced in the 2017 Review of
National Aged Care Quality Regulatory
Processes in response to the Oakden
scandal, which recommended various
strategies to strengthen the protection of
consumers in residential aged care while
leaving intact the tenet that aged care is
like any other good or service and best
produced and distributed through markets.
Two key points here are that making
personalised budgets, or consumer-
directed care as it is called, in itself, does
not guarantee increased choice and
control for older people. Other factors
play a crucial role, including the size of
the budget, the vulnerability of purchasing
a product in a time of crisis, the market
dimension and the personal domains.
Secondly, market-driven care is not a
guarantee of quality through competition.
The question of whether marketisation
and for-profit provision of care are
positive developments for citizens and
the care labour force has been the focus
of empirical research internationally. The
evidence, not only in Australia, but in the
UK, Ireland and Europe, needs careful
consideration. Research into aged care
in England, Sweden and Australia has
found no firm evidence that increased
competition and marketisation increases
quality or lowers costs. On the contrary,
they have been associated with increased
inequalities among consumers, high
staff turnover and lower ratios of staff to
consumer in residential care, as well as
lower quality of care.
In Norway, resistance to markets
has been strong and has led to the
development of innovative system-wide
alternatives to competition, including
cooperation and community participation
in the protection of consumers, planning
and implementation of eldercare
protections, while legislating protections
for the non-profit institutions from the
effects of marketisation.
As the Royal Commission into Aged
Care Quality and Safety uncovers more
evidence of malpractice, neglect and poor
care in institutional care, it is important to
reflect on the ongoing crisis in the home
care sector. We need to question the
manner in which the rhetoric of choice,
control and independence associated with
personalised budgets has silenced the less
attractive attributes and consequences of
making social care a market product for
frail, older consumers despite considerable
vulnerability and disadvantage when it
comes to purchasing care. ■
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